Typhoid fever in children in Goroka, Papua New Guinea.

BACKGROUND: Typhoid is endemic in many low-income countries, including in Papua New Guinea. This study aimed to describe the burden and clinical features of typhoid in children in a provincial hospital, to describe environmental conditions that lead to typhoid, and to document the antibiotic sensitivity of Salmonella spp. in the Eastern Highlands Province. METHODS: A combined retrospective and prospective study of children admitted to with clinical features of typhoid to the Goroka Hospital throughout 2022. RESULTS: The study included 98 children, of which 54% were female. The median age was 8 (IQR 5-10.6) years. Over 60% of the patients were from Goroka District, the peri-urban area encompassing the town and surrounds. Ninety-four percent (92) of the patients used a pit latrine as a toilet and only 28% had access to treated water. Neuropsychiatric symptoms were common (60%), as was leukopenia (48%), thrombocytopenia (52%) and anaemia (42%). Thirty-seven patients had positive blood cultures for Salmonella typhi; all isolates were sensitive to third-generation cephalosporins, pefloxacin, ampicillin, trimethoprim and sulfamethoxazole, and only 54% sensitive to chloramphenicol. The median duration of hospitalisation was 6 days (IQR). There were no deaths. CONCLUSION: Prompt public health actions are needed to reduce the burden of typhoid infection in the Papua New Guinea. The conjugate typhoid vaccine should be considered in the highlands region, where typhoid is most endemic.

Child health nurses in Solomon Islands, piloting the 'Bachelor of nursing: Child health'.

AIM: In 2016, the Solomon Islands National University developed and implemented the country's first nursing specialisation in child health, the Bachelor of Nursing: Child Health. This qualitative study aimed to explore the experiences of the first cohort of students (n = 14) during this course in order to evaluate the programme. BACKGROUND: The Bachelor of Nursing: Child Health was implemented in 2016 to develop nurses' knowledge and skills in child health and improve child health outcomes and so on. DESIGN: The qualitative evaluation study used an exploratory, descriptive design. METHODS: The 14 nurses who constituted the first cohort of students were selected as study participants. Individual semi-structured interviews were conducted between August and December 2018. Thematic analysis was undertaken following the Braun and Clarke six-phase process to generate themes and sub-themes from the data. The Consolidated Criteria for Reporting Qualitative Research checklist guided the reporting of the study. RESULTS: Interviews revealed important feedback about the course, including areas to strengthen and avenues to improve it in the future. Four themes emerged: learning during the Bachelor of Nursing: Child Health, support during the course, challenges experienced during the course and suggested course improvements in the future. The study found that theoretical sessions combined with practical and interactive activities were most effective in learning both theoretical concepts and their related clinical applications and skills. Although support was generally available during the course, participants emphasised their responsibility to take the lead in their learning and seek support when required. The lack of mentoring combined with logistical difficulties were perceived as barriers to learning. Participant recommendations support further development of the child health nursing specialisation, with specific strengthening in areas such as teaching and mentoring, logistics, course curriculum and human and material resources. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Given the potential benefits of increasing nurses' knowledge and skills in child health and paediatric care on reducing neonatal and child mortality and morbidity, ongoing support for the implementation of this course in Solomon Islands and more broadly across the Pacific region is recommended. The provision of such support is a local, regional and a global responsibility. Indeed, Sustainable Development Goal 3c calls for a substantial increase in health financing and in the recruitment, development, training and retention of the health workforce in low- and middle-income countries. CONCLUSIONS: Results of the evaluation demonstrate the positive aspects of the course in relation to content and curriculum delivery strategies as well as identifying areas where further refinement and strengthening is required.

Making respiratory care safe for neonatal and paediatric intensive care unit staff: mitigation strategies and use of filters.

Background: Many medical devices in pediatric and newborn intensive care units can potentially expose healthcare workers (HCWs) and others to transmission of respiratory and other viruses and bacteria. Such fomites include ventilators, nebulizers, and monitoring equipment. Approach: We report the general, novel approach we have taken to identify and mitigate these risks and to protect HCWs, visitors and patients from exposure while maintaining the optimal performance of such respiratory equipment. Findings: The approach combined a high level of personal protective equipment (PPE), strict hand hygiene, air filtration and air conditioning and other relevant viral risk mitigation guidelines. This report describes the experiences from the SARS-CoV-2 pandemic to provide a reference framework that can be applied generally. The steps we took consisted of auditing our equipment and processes to identify risk through sources of potentially contaminated gas that may contain aerosolized virus, seeking advice and liaising with suppliers/manufacturers, devising mitigation strategies using indirect and direct approaches (largely filtering), performing tests on equipment to verify proper function and the absence of negative impacts and the development and implementation of relevant procedures and practices. We had a multidisciplinary team to guide the process. We monitored daily for hospital-acquired infections among staff caring for SARS-CoV-2 patients. Conclusion: Our approach was successful as we have continued to offer optimal intensive care to our patients, and we did not find any healthcare worker who was infected through the course of caring for patients at the bedside. The lessons learnt will be of benefit to future local outbreaks or pandemics.

Agreement Between Measured Weight and Fluid Balance in Mechanically Ventilated Children in Intensive Care.

OBJECTIVES: To investigate the agreement between change in body weight (BW) and fluid balance (FB), and the precision and safety of BW measurement in mechanically ventilated infants in intensive care. DESIGN: Prospective observational study. SETTING: Tertiary PICU. PATIENTS: Infants following cardiac surgery, at baseline, 24 hours, and 48 hours. INTERVENTIONS: BW and FB measurement at three time points. MEASUREMENTS AND MAIN RESULTS: Between May 2021 and September 2022, we studied 61 children. The median age was 8 days (interquartile range [IQR], 1.0-14.0 d). The median BW at baseline was 3,518 g (IQR, 3,134-3,928 g). Change in BW was -36 g (IQR, -145 to 105 g) and -97 g (IQR, -240 to -28 g) between baseline and 24 hours, and between 24 and 48 hours, respectively. Change in FB was -82 mL (IQR, -173 to 12 mL) and -107 mL (IQR, -226 to 103) between baseline and 24 hours, and between 24 and 48 hours, respectively. In Bland-Altman analyses, the mean bias between BW and FB at 24 and 48 hours was 54 g (95% CI, 12-97) and -43 g (95% CI, -108 to 23), respectively. This exceeded 1% of the median BW, and limits of agreement ranged from 7.6% to 15% of baseline BW. The precision of paired weight measurements, performed sequentially at each time interval, was high (median difference of ≤1% of BW at each time point). The median weight of connected devices ranged from 2.7% to 3% of BW. There were no episodes of tube or device dislodgments and no change in vasoactive therapies during weight measurements. CONCLUSIONS: There is moderate agreement between the changes in FB and BW, albeit greater than 1% of baseline BW, and the limits of this agreement are wide. Weighing mechanically ventilated infants in intensive care is a relatively safe and precise method for estimating change in fluid status. Device weight represents a relatively large proportion of BW.

Low birthweight newborns in Vanuatu: A longitudinal follow-up study.

AIM: Medical care and technology have increased the survival of low birthweight babies (LBW), but especially in low- and middle-income settings the longer term thriving of such babies is not assured because of their fragility, limited services and difficult access after discharge from hospital. In Vanuatu, a Pacific nation of dispersed islands, improving LBW outcomes and survival remains a significant challenge. In this study, we prospectively document the survival, developmental and nutritional outcomes of a cohort of LBW over the first year of life. We also explored the mother's experiences of caring for an LBW baby in hospital and at home. METHODS: A prospective descriptive cohort study of 49 newborns weighing less than 2.5 kg, born between April and August 2019. Data were recorded on their hospital stay, and they were followed up at 6 and 12 months post-discharge and outcomes recorded. Developmental milestones were assessed using the Denver Developmental Screening Test, using milestones appropriate for corrected age. Qualitative interviews were conducted to identify experiences and challenges the mothers faced in caring for their LBW baby. RESULTS: The mean birthweight was 1800 g at 35 weeks gestation (between 2nd and 9th centile). At 6 months of age the median weight was 6.5 kg (9th centile) and at 12 months it was 7.8 kg (9th centile). Three infants died in the first 6 months post-discharge. By 12 months of age, the proportion of infants who had achieved milestones of social and emotional (90%), language and communication (97%), cognition (85%) and motor (69%) development. One had evidence of retinopathy, and 19 had clinical anaemia. Mothers identified several stressors that they attributed as risk factors for premature delivery and outlined the difficulties and isolation of caring for an LBW baby. CONCLUSIONS: It is vital that all LBW babies are followed up in the years after discharge: nutritional, developmental and general health outcomes were generally good; however, post-discharge deaths are more common in this group than in the general population. Equally important is the support for mothers of LBW babies to achieve better outcomes.

Children with palliative care needs in Papua New Guinea, and perspectives from their parents and health care workers: a qualitative study.

INTRODUCTION: The World Health Organisation defines paediatric palliative care (PPC) as caring for the child's body, mind, and spirit, and giving support to the family. In life-limiting conditions it is important that palliative support can be provided even when curative attempts are being utilised. In Papua New Guinea, as in other low- and middle-income countries there is a lack of services and training on PPC. This study aims to describe the characteristics of children with palliative care needs and to assess the perspectives of their parents and health care workers. METHODS: A descriptive qualitative study was carried out over 5 months in 2022 at the Port Moresby General Hospital children's wards. Clinical information was gathered from the admission charts of children with life threatening and life limiting conditions and a recorded interview was carried out with the children's parents. A focus group interview with 10 experienced nurses caring for these children was video recorded. The recorded interviews were subjected to thematic analysis. RESULTS: Twenty children and their parents were included in this study. Nine had a cancer diagnosis and 11 had a chronic progressive condition. The common clinical characteristics of children with palliative care needs were pain (n = 9) and shortness of breath (n = 9), and most children had more than one symptom. Several themes were identified in the parent interviews. Most parents could not name their child's diagnosis, but they were able to correctly describe their child's condition using their own terms. Most parents felt involved in their child's management and were satisfied with the care provided. Parents were psychologically affected by their child's situation but were hopeful that God and the medicines would heal their child. Ten nurses were involved in a focus-group interview. Most nurses' understanding of palliative care was from experience not from formal training, but most felt confident in identifying the physical, emotional, and spiritual needs of the children. Understanding of analgesia was limited, as was the availability of appropriate medications included in the WHO Analgesic Ladder. CONCLUSION: There is a need for a systematic approach to palliative care in Papua New Guinea. Palliative care can be integrated into an overall approach to quality of paediatric care. It is relevant to a broad section of children with severe chronic or malignant conditions and can be carried out with limited resources. It does require some resources, further training and education, and increased provision of basic drugs for symptom control.

Risk factors for healthcare-associated infection among children in a low-and middle-income country.

BACKGROUND: Healthcare-associated infections (HAI) are one of significant causes of morbidity and mortality. Evaluating risk factors associated with HAI are important to improve clinical outcomes. We aimed to evaluate the risk factors of HAI in children in a low-to middle-income country. METHODS: A prospective cohort study was conducted during 43 months at a teaching hospital in Yogyakarta, Indonesia. All consecutive patients admitted to pediatric ICU and pediatric wards > 48 h were eligible. Those eligible patients were observed daily to identify the presence of HAI based on CDC criteria. The risk factors of HAI were identified. Multivariable logistic regression was used to identify independent risk factors. RESULTS: Total of 2612 patients were recruited. Of 467 were diagnosed as HAI. The cumulative incidence of HAI was 17.9%. In the multivariable analysis; length of stay > 7 days, severe sepsis, use of urine catheter, central venous catheter (CVC), non-standardized antibiotics, and aged < 1 year were independently associated with increased risk of HAI with adjusted OR (95%CI): 5.6 (4.3-7.3), 1.9 (1.3-2.9), 1.9 (1.3-2.6), 1.8 (1.1-2.9), 1.6 (1.2-2.0), and 1.4 (1.1-1.8), respectively. CONCLUSIONS: This study found that length of stay > 7 days, use of urine catheter and CVC, non-standardized antibiotic use, aged < 1 year, and had a diagnosis of severe sepsis increased risk of HAI.

Fluid Accumulation in Mechanically Ventilated, Critically Ill Children: Retrospective Cohort Study of Prevalence and Outcome.

OBJECTIVES: To describe the prevalence, patterns, explanatory variables, and outcomes associated with fluid accumulation (FA) in mechanically ventilated children. DESIGN: Retrospective cohort study. SETTING: Tertiary PICU. PATIENTS: Children mechanically ventilated for greater than or equal to 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Between July 2016 and July 2021, 1,636 children met eligibility criteria. Median age was 5.5 months (interquartile range [IQR], 0.7-46.5 mo), and congenital heart disease was the most common diagnosis. Overall, by day 7 of admission, the median maximum cumulative FA, as a percentage of estimated admission weight, was 7.5% (IQR, 3.3-15.1) occurring at a median of 4 days after admission. Overall, higher FA was associated with greater duration of mechanical ventilation (MV) (mean difference, 1.17 [95% CI, 1.13-1.22]; p < 0.001]), longer intensive care length of stay (LOS) (mean difference, 1.16 [95% CI, 1.12-1.21]; p < 0.001]), longer hospital LOS (mean difference, 1.19 [95% CI, 1.13-1.26]; p < 0.001]), and increased mortality (odds ratio, 1.31 [95% CI, 1.08-1.59]; p = 0.005). However, these associations depended on the effects of children with extreme values, and there was no increase in risk up to 20% FA, overall, in children following cardiopulmonary bypass and in children in the general ICU. When excluding children with maximum FA of >10%, there was no association with duration of MV (mean difference, 0.99 [95% CI, 0.94-1.04]; p = 0.64) and intensive care or hospital LOS (mean difference, 1.01 [95% CI, 0.96-1.06]; p = 0.70 and 1.01 [95% CI, 0.95-1.08]; 0.79, respectively) but an association with reduced mortality 0.71 (95% CI, 0.53-0.97; p = 0.03). CONCLUSIONS: In mechanically ventilated critically ill children, greater maximum FA was associated with longer duration of MV, intensive care LOS, hospital LOS, and mortality. However, these findings were driven by extreme values of FA of greater than 20%, and up to 10%, there was reduced mortality and no signal of harm.

Influenza vaccine administration in a paediatric intensive care unit.

AIM: We describe the clinical profile of children and outcomes of influenza immunisation for patients in a paediatric intensive care unit (PICU). METHODS: Over two influenza seasons: 19/04/2018 to 07/08/2018 and 02/05/2019 to 10/10/2019, an immunisation nurse and PICU nurse coordinator met weekly and identified patients to receive the influenza vaccine. An inpatient list of PICU patients was screened for eligible patients: greater than 6 months of age, did not have imminent procedures (e.g. surgery) or were not critically unwell, as determined by the treating team, to receive the influenza vaccine. Patients were excluded if they had undergone surgery in the previous 24 hours or were being treated palliatively. RESULTS: Sixty patients in PICU were identified, with 43% (26/60) receiving the vaccine while in PICU and 17% (10/60) once discharged from PICU to the general ward environment. The majority of patients immunised were in PICU due to cardiac surgery/cardiology or general medical conditions, such as cerebral palsy or RSV bronchiolitis. There were no reported adverse events following immunisation. CONCLUSIONS: We have demonstrated the suitability and acceptability of children in the PICU receiving the seasonal influenza vaccine and tailored interventions to follow-up once discharged from PICU to optimise protection.

Prevalence and outcome of lymphopenia in the Paediatric Intensive Care Unit: A prospective observational study.

AIM: Leukopenia (lymphopenia or neutropenia) may be an important marker of altered immunity and risk in children with critical illness. We aimed to evaluate the prevalence, course, and outcome of leukopenia in children admitted to Paediatric Intensive Care Unit (PICU). METHODS: All consecutive children (n = 200) admitted to PICU for any reason except malignancy or pre-existing immune deficiency were enrolled during June-August 2018. RESULTS: Median (interquartile range) age was 2.2 (0.6-8.5) years. About 52% (n = 103) had undergone a surgical procedure; 34% (n = 68) being cardiac surgery. Among medical illnesses, respiratory disorders were the most common (n = 39, 20%). Laboratory confirmed infections were present in 63 (31.5%) children. Leukopenia was identified in 135 (67.5%) children in the first week; 117 (58.5%) had only lymphopenia, 16 (8%) had both lymphopenia and neutropenia, and 2 (1%) had only neutropenia. In 69 children who had follow-up blood counts, lymphopenia resolved in 33 (48%) within 48 h and in another 20 (29%) by 4 days, and in a further 10 (14%) by 7 days. Children with lymphopenia had higher frequency of cardiac surgery, longer cardiopulmonary bypass time, greater need for invasive ventilation and vasopressor/inotrope therapy, and a higher probability of organ failure on day 4 and longer hospital stay. CONCLUSION: In critically ill children, lymphopenia is very common, often transient, but may be associated with unfavourable outcomes. Further studies with follow-up of blood counts in a larger sample are required to determine the course and outcomes of lymphopenia.

Characteristics, management and changing incidence of children with empyema in a paediatric intensive care unit.

AIM: Paediatric intensive care unit (PICU) admissions for empyema increased following the 13-valent pneumococcal conjugate vaccine (PCV13). We describe the clinical characteristics, management and outcomes for children with empyema and compare incidence before and after PCV13. METHODS: Retrospective study of patients <18 years admitted to The Royal Children's Hospital Melbourne PICU with empyema between January 2016 and July 2019. We investigated the incidence of empyema during two time periods: 2007-2010 (pre-PCV13) and 2016-2019 (post-PCV13). RESULTS: Seventy-one children (1.9% of all PICU admissions) were admitted to PICU with empyema between 2016 and 2019. Sixty-one (86%) had unilateral disease, 11 (16%) presented with shock and 44 (62%) were ventilated. Streptococcus pneumoniae and group A Streptococcus were the most commonly identified pathogens. Forty-five (63%) were managed with video-assisted thoracoscopic surgery (VATS). There was a 31% reduction in empyema hospitalisations as a proportion of all hospitalisations (IRR 0.69, 95% CI 0.59-0.8), but a 2.8-fold increase in empyema PICU admissions as a proportion of all PICU admissions (95% CI 2.2-3.5, P < 0.001). For the PICU cohort, this was accompanied by reduction in PIM2 probability of death (median 1% vs. 1.9%, P = 0.02) and duration of intubation (median 69 h vs. 126.5 h, P = 0.045). CONCLUSIONS: In children with empyema in PICU 62% required ventilation, 16% had features of shock and 63% received VATS. Empyema admissions, as a proportion of all PICU admissions, increased in the era post-PCV13 compared to pre-PCV13 despite no increase in illness severity at admission.

Characteristics and outcomes of SARS-CoV-2 infection in Victorian children at a tertiary paediatric hospital.

AIM: Victoria experienced two 'waves' of COVID-19 between March and September 2020 and more cases than any other jurisdiction in Australia. Although world-wide reports of COVID-19 reflect that children are less likely to experience severe disease compared with adults, hospitalisations and deaths have been reported. We report testing and outcomes of children with SARS-CoV-2 infection presenting to a tertiary paediatric hospital in Melbourne. METHODS: We conducted a prospective cohort study at The Royal Children's Hospital (RCH), including all children and adolescents (aged 0-18 years) who presented and were tested for SARS-CoV-2 over a 6-month period, between 21 March 2020, up to the 21 September 2020. Detailed epidemiological and clinical data were recorded. RESULTS: A total of 19 708 tests for SARS-CoV-2 were performed in 14 419 patients. One hundred and eighty patients tested positive for SARS-CoV-2 (1.2%). 110 (61%) were symptomatic, 60 (33%) were asymptomatic and 10 (6%) were pre-symptomatic. Close contacts of a positive case were associated with a higher risk of a testing positive for SARS-CoV-2 (120/2027 (6%) vs. 60/14589 (0.4%), RD 5.5 (95% CI 4.5 to 6.5), P < 0.001). Eighteen (10%) SARS-CoV-2-positive patients were admitted to hospital with one patient requiring intensive care. All patients recovered fully with no deaths. CONCLUSION: In Victorian children presenting to a tertiary hospital, SARS-CoV-2 infection caused predominantly mild or asymptomatic infection, with most children not requiring hospitalisation.

Gastroschisis in a premature infant in Papua New Guinea: initial treatment with a normal saline bag silo.

This case report describes the staged management gastroschisis in a low-birthweight baby in Papua New Guinea, where a silo was fashioned using a normal saline bag to protect the bowel, while the baby stabilised and was ready for later abdominal wall closure. We discuss the need for improvisation to prevent sepsis and other complications and to improve outcomes for congenital malformations where resources are limited.

Hemodynamic Response to Fluid Boluses for Hypotension in Children in a Cardiac ICU.

OBJECTIVES: To describe the hemodynamic response to fluid boluses for hypotension in children in a cardiac ICU. DESIGN: A prospective, observational study. SETTING: Single-centered cardiac ICU. PATIENTS: Children in a cardiac ICU with hypotension. INTERVENTIONS: Clinician prescribed fluid bolus. MEASUREMENTS AND MAIN RESULTS: Sixty-four fluid boluses were administered to 52 children. Fluid composition was 4% albumin in 36/64 (56%), 0.9% saline in 18/64 (28%), and cardiopulmonary bypass pump blood in 10/64 (16%). The median volume and duration were 5.0 mL/kg (interquartile range, 4.8-5.4) and 8 minutes (interquartile range, 4-19), respectively. Hypovolemia/low filling pressures was the most common additional indication (25/102 [25%]). Mean arterial pressure response, defined as a 10% increase from baseline, occurred in 42/64 (66%) of all fluid boluses at a median time of 6 minutes (interquartile range, 4-11). Mean arterial pressure responders had a median peak increase in the mean arterial pressure of 15 mm Hg (43 mm Hg [interquartile range, 29-50 mm Hg] to 58 mm Hg [interquartile range, 49-65 mm Hg]) at 17 minutes (interquartile range, 14-24 min) compared with 4 mm Hg (48 mm Hg [interquartile range, 40-51 mm Hg] to 52 mm Hg [interquartile range, 45-56 mm Hg]) at 10 minutes (interquartile range, 3-18 min) in nonresponders. Dissipation of mean arterial pressure response, when defined as a subsequent decrement in mean arterial pressure below 10%, 5%, and 2% increases from baseline, occurred in 28/42 (67%), 18/42 (43%), and 13/42 (31%) of mean arterial pressure responders, respectively. Cardiopulmonary bypass pump blood was strongly associated with peak change in mean arterial pressure from baseline (coefficient 11.0 [95% CI, 4.3-17.7]; p = 0.02). Fifty out of 64 (78%) were receiving a vasoactive agent. However, change in vasoactive inotrope score was not associated with change in mean arterial pressure (coefficient 2.3 [95% CI, -2.5 to -7.2]; p = 0.35). Timing from admission, nor fluid bolus duration, influenced mean arterial pressure response. CONCLUSIONS: In children with hypotension in a cardiac ICU, the median dose and duration of fluid boluses were 5 mL/kg and 8 minutes. Peak response occurred shortly following administration and commonly returned to baseline.

Living with thalassaemia in Papua New Guinea, the experience of children, adolescents and their families.

AIM: Thalassaemia, the commonest genetic blood disorder in Papua New Guinea (PNG) presents daunting challenges for the affected children, their parents and families, and the health system. We aimed to describe the quality of life of affected children and adolescents and the experience of and difficulties faced by their parents in the setting of a tertiary referral hospital in PNG. METHODS: A mixed-methods longitudinal study involving baseline questionnaire, then serial interviews with parents, children and adolescents living with ß-thalassaemia attending Port Moresby General Hospital. RESULTS: Twenty-one patients and their families were interviewed over a 6-month period. Most families originated outside the National Capital District and had migrated to be near the Port Moresby General Hospital and its blood bank services. Thirteen patients had at least one affected sibling and four families had experienced the death of at least one other affected child. No child was receiving chelating agents, and most had clinical evidence of iron overload. There were important impacts of thalassemia on quality of life, including very poor school attendance and some aspects of children's self-perception. Families faced significant burdens and made genuine sacrifices to care for their children. CONCLUSION: Regular blood transfusions increase the life-span of children with thalassaemia but there is a need to achieve a hyper-transfusion regimen coupled with chelation therapy. As for all chronic illness, a focused and holistic approach is needed to improve the quality of life for affected children and their families.

Rural healthcare workers views on the introduction of solar power and oxygen concentrators in health facilities in Papua New Guinea: a qualitative study.

INTRODUCTION: A motivated, well supported rural health workforce is required to provide appropriate child health services to the rural population. This study explored the views of rural health workers in Papua New Guinea on the impact of a program to improve oxygen delivery systems and to provide reliable power to their health facilities. METHODS: A pre-tested, self-administered open question survey was carried out among rural health workers from 38 health facilities in which oxygen concentrators had been installed, including 30 with solar power. Thematic analysis was carried out on the responses. RESULTS: The program was highly appreciated. Benefits extended beyond the ability to treat children with a reliable source of oxygen. Participants reported the positive community response to improved patient care and avoiding patient referrals. They stressed their wish for further improvements in infrastructure and for continuing education. CONCLUSION: The program improved morale and job satisfaction. The views of rural health workers are important in assessing program effectiveness.

The process of implementing child mortality reviews in low- and middle-income countries: a narrative systematic review.

OBJECTIVES: This review aims to describe the processes that have been used to implement child mortality reviews in LMICs and to identify the facilitators and barriers to their implementation and impact. This will help to inform healthcare professionals and managers planning to implement a child mortality review in their setting. METHODS: MEDLINE and Embase databases were searched for papers published between January 1996 and April 2019. Studies reporting the implementation of a child mortality review process in LMICs were considered eligible. A narrative approach was used to describe the stages in the audit process outlined in the WHO 'Operational guide for facility-based audit and review of paediatric mortality' which were completed, and to synthesise the barriers and facilitators to implementation and impact of the child mortality review process. RESULTS: From 776 potentially relevant articles, seven studies were included. In six studies, problems contributing to child deaths and possible solutions were identified, in four, these solutions were implemented, and in one, this implementation was monitored. Key factors influencing implementation and impact were attendance at meetings, use of a blame-free approach, allocating adequate human and financial resources to make changes, and level of engagement from leadership. CONCLUSIONS: Despite the common use of mortality reviews in paediatric departments, there are few studies published on this topic. The transition from identifying problems and solutions to implementing and monitoring action plans appears to be the most difficult aspect of the process, which requires commitment of adequate resources and strong leadership.

OBJECTIFS: Cette analyse vise à décrire les processus qui ont été utilisés pour mettre en œuvre des analyses de la mortalité infantile dans les PRFI et pour identifier les facilitateurs et les obstacles à leur mise en œuvre et à leur impact. Cela aidera à informer les professionnels de la santé et les gestionnaires qui prévoient de mettre en œuvre une analyse de la mortalité infantile dans leurs cadres. MÉTHODES: Les bases de données MEDLINE et EMBASE ont été recherchées pour les articles publiés entre janvier 1996 et avril 2019. Les études signalant la mise en œuvre d'un processus d'analyse de la mortalité infantile dans les PRFI ont été jugées éligibles. Une approche narrative a été utilisée pour décrire les étapes du processus d'audit décrites dans le "Guide opérationnel de l'OMS pour l'audit et l'analyse de la mortalité pédiatrique dans les établissements" qui ont été achevées, et pour synthétiser les obstacles et les facilitateurs à la mise en œuvre et à l'impact du processus d'analyse de la mortalité infantile. RÉSULTATS: Sur 776 articles potentiellement pertinents, sept études ont été incluses. Dans six études, des problèmes contribuant aux décès d'enfants et des solutions possibles ont été identifiés, dans quatre, ces solutions ont été mises en œuvre et dans une, cette mise en œuvre a été suivie. Les facteurs clés influençant la mise en œuvre et l'impact étaient: la participation aux réunions, l'utilisation d'une approche sans reproche, l'allocation de ressources humaines et financières adéquates pour apporter des changements et le niveau de l'engagement de la direction. CONCLUSIONS: Malgré l'utilisation courante des analyses de mortalité dans les services de pédiatrie, peu d'études ont été publiées sur ce sujet. La transition de l'identification des problèmes et des solutions à la mise en œuvre et au suivi des plans d'action semble être l'aspect le plus difficile du processus, qui nécessite l'engagement de ressources adéquates et un leadership fort.

Healthcare worker knowledge and skills following coaching in WHO early essential newborn care program in the Solomon Islands: a prospective multi-site cohort study.

BACKGROUND: Newborn mortality in Oceania declined slower than other regions in the past 25 years. The World Health Organization (WHO) introduced the Early Essential Newborn Care program (EENC) in 2015 in Solomon Islands, a Small Island Developing State, to address high newborn mortality. We explored knowledge and skills retention among healthcare workers following EENC coaching. METHODS: Between March 2015 and December 2017, healthcare workers in five hospitals were assessed: pre- and post-clinical coaching and at a later evaluation. Standardised written and clinical skills assessments for breathing and non-breathing baby scenarios were used. Additionally, written surveys were completed during evaluation for feedback on the EENC experience. RESULTS: Fifty-three healthcare workers were included in the evaluation. Median time between initial coaching and evaluation was 21 months (IQR 18-26). Median written score increased from 44% at baseline to 89% post-coaching (p < 0.001), and was 61% at evaluation (p < 0.001). Skills assessment score was 20% at baseline and 95% post-coaching in the Breathing Baby scenario (p < 0.001). In the Non-Breathing Baby scenario, score was 63% at baseline and 86% post-coaching (p < 0.001). At evaluation, median score in the Breathing Baby scenario was 82% a reduction of 13% from post-coaching (p < 0.001) and 72% for the Non-Breathing Baby, a reduction of 14% post-coaching (p < 0.001). Nurse aides had least reduction in evaluation scores of - 2% for the Breathing Baby and midwives - 10% for the Non-Breathing Baby respectively from post-coaching to evaluation. CONCLUSIONS: EENC coaching resulted in immediate improvements in knowledge and skills but declined over time. Healthcare workers who used the skills in regular practice had higher scores. Complementary quality improvement strategies are needed to sustain resuscitation skills following training over time. TRIAL REGISTRATION: Australia New Zealand Trial Registry, Retrospective Registration (12/2/2019), registration number ACTRN12619000201178.

Ten years of severe respiratory syncytial virus infections in a tertiary paediatric intensive care unit.

AIM: To describe the epidemiology and treatment of respiratory syncytial virus (RSV) infection in a tertiary paediatric intensive care unit (PICU), including the clinical presentations, comorbidities, respiratory support required, costs and outcomes. METHODS: This study was an analysis of a database for all children with RSV infections admitted to the PICU in Melbourne between 2005 and 2015. RESULTS: A total of 604 episodes of community-acquired RSV infections were analysed, and the median age of children was 4 months (interquartile range 2-14 months); 94% of cases had lower respiratory tract infection, principally bronchiolitis, and 8.9% presented with extrapulmonary features. Respiratory support included humidified high-flow nasal cannula oxygen therapy (76% of patients since its introduction in 2011), non-invasive ventilation (41%) and intubation and mechanical ventilation (32%). Almost half (n = 270; 45%) had one or more pre-existing comorbid condition. Risk factors for intubation and mechanical ventilation were presence of comorbidities (odds ratio 1.97; confidence interval 1.39-2.79, P < 0.001) and transfer from an external hospital (odds ratio 1.82; confidence interval 1.58-2.57, P < 0.001). Of the children without pre-existing comorbidities, 25% required intubation and mechanical ventilation. Following the introduction of humidified high-flow nasal cannula oxygen therapy, the number of annual PICU admissions for RSV infection doubled; however, the number of children requiring intubation remained unchanged. The median length of intensive care unit stay was 3.7 days and further hospital stay was 3.6 days, and the average cost per case was approximately AU$20000. CONCLUSIONS: RSV infection carries a high burden in PICU, in bed-days and cost. Chronic comorbidities and transfer from a peripheral hospital were associated with a higher rate of need for mechanical ventilation.

Cause-specific neonatal morbidity and mortality in the Solomon Islands: An assessment of data from four hospitals over a three-year period.

AIM: Data on stillbirths and neonatal morbidity and mortality in low-middle income Pacific Island Nations such as Solomon Islands is limited, partly due to weak health information systems. We describe the perinatal mortality and clinical factors associated with poor newborn outcomes at four hospitals in Solomon Islands. METHODS: This was a registry based retrospective cohort study at three provincial hospitals and the National Referral Hospital (NRH) from 2014-2016 inclusive. RESULTS: 23 966 labour ward births and 3148 special care nursery (SCN) admissions were reviewed. Overall still birth rate was 29.2/1000 births and the perinatal mortality rate was 35.9/1000 births. PNMR were higher in provincial hospitals (46.2, 44.0 and 34.3/1000) than at NRH (33.3/1000). The commonest reasons for admission to SCN across the hospitals were sepsis, complications of prematurity and birth asphyxia. SCN mortality rates were higher in the 3 provincial hospitals than at NRH (15.9% (95/598) vs. 7.9% (202/2550), P value <0.01). At NRH, the conditions with the highest case fatality rates were birth asphyxia (21.3%), congenital abnormalities (17.7%), and prematurity (15.1%). Up to 11% of neonates did not have a diagnosis recorded. CONCLUSIONS: The perinatal mortality rates are high and intrapartum complications, prematurity and sepsis are the main causes of morbidity and mortality for neonates at hospitals in Solomon Islands. Stillbirths account for 81% of perinatal deaths. These results are useful for planning for quality improvement at provincial level. Improved vital registration systems are required to better capture stillbirths and neonatal outcomes.